What Is Dental Insurance (& What Does It Cover)?

There’s no getting around it: insurance is a pain. Having it is a pain. Not having it is a pain.

That said, when it comes to navigating dental costs, insurance is a nice benefit, especially if you’re anticipating getting orthodontic treatment (or any other major work, really). Maybe you’re contemplating getting insurance, or you’re trying to sort through what your current plan will get you.

In this guide, we’ll help take some of the guesswork out of dental insurance. By the end, you’ll have a pretty clear picture of the different insurance types, what treatments are covered, how much you could expect to spend (with or without insurance), and more. Let’s dig in.

Sorting Through Insurance Jargon

Before we get knee-deep in the nitty-gritty of insurance, let’s sort through the industry jargon. Yeah, we get it: definitions aren’t super fun. But insurance companies will throw lots of terms your way (and they expect you to know them). Here are a few key terms you’ll want to know.

• Deductible: Each year, your insurance company will expect you to shell out a set amount for your treatment. This is an annual out-of-pocket expense, and once you’ve met the dollar amount set, your insurance company will begin covering your expenses. How big or small your deductible is depends on your policy; usually, plans with a small monthly premium have higher deductibles and higher premiums have lower deductibles.

• Monthly premium: Much like you pay a monthly subscription plan for Netflix or Hulu, you’ll have to pay a monthly “subscription fee” to pay for your insurance coverage. The impact this premium has on your wallet each month will depend on your policy.

• Copay: Also called a copayment, a copay is a set amount you pay for certain services after meeting your deductible; insurance covers the rest. For example, you might have a certain copay for a visit with a primary care doctor, a different copay for generic prescriptions, and yet another copay to see a specialist.

• Coinsurance: Like a copay, coinsurance is an expense you’ll pay after meeting your deductible. Usually, coinsurance is not a set dollar amount; instead, it’s a percentage of the total cost for the service. For example, you might pay a 25% coinsurance for your follow-up appointment for a broken bone, and your insurance would pay the other 75%.

• Maximum annual benefit: After you’ve met your deductible and your benefits kick in, your insurance company will still only pay so much. Your maximum annual benefit is the total amount your insurance will pay on your behalf each year. Like the copay and coinsurance, the size of your maximum annual benefit will depend on the terms of your policy.

• Maximum lifetime benefit: In addition to a maximum annual benefit, insurance companies will often set lifetime caps for certain purchases. For example, a policy with orthodontic benefits might set a maximum lifetime benefit of $1,500 for braces or Invisalign. So they might help pay for $1,500 worth of your first orthodontic treatment, but if you need refinements later, you’ll pay the rest yourself.

• In-network vs. out-of-network: Insurance companies typically establish a network of providers that they team up with to balance costs, maintain quality, and manage expenses. As a result, when you sign up for an insurance policy, your insurer will provide you with a list of providers who are “in-network” with their company. Some companies will only cover procedures provided by in-network doctors. Others will give you incentive to stick with an in-network provider but still cover part of your bill.

And with those terms in mind, let’s talk about different types of insurance.

Types of Insurance & Other Cost-Reducing Plans

Not only are there lots of different insurance companies, but there are a bunch of different types of insurance and insurance alternatives. Your options are almost limitless. But no two plans are exactly the same.

Dental insurance

Let’s make one thing clear: dental insurance and health insurance aren’t the same thing, especially for adults. Kids get a little lucky, since routine dental procedures like cleanings, X-rays, and so on are viewed as beneficial to their overall health. But after age 18, they’re viewed as dental procedures, not health procedures. So if you’re hoping to get coverage for your preventative and restorative dental care, you’ll need to get a dental insurance plan in addition to your health insurance.

Many dental insurance plans require a separate deductible for each insured person. For example, you might need to pay $100 out of pocket. That number can be even higher depending on your policy’s coverage. After you meet your deductible, most routine procedures like cleanings, X-rays, fillings, and exams are covered in full (or close). More extensive procedures like root canals or crowns will cost more. Many of these policies have a maximum annual benefit of around $1,000 to $2,000.

And there are a bunch of different varieties of dental insurance, too.

• Dental HMOs: Short for Health Maintenance Organization, HMO providers will grant compensation for most dental services provided by in-network dentists. Out-of-network care is usually not covered except in emergencies. These policies emphasize preventative care and maintenance.

• Dental PPOs: Short for Preferred Provider Organization, PPO providers have a list of in-network doctors that they prefer to work with. You’ll get the best benefits by using an in-network doctor, but if you have a different doctor you’d rather work with, you’ll still get some coverage—just not quite as much.

• Dental indemnity plans: Instead of making you choose an in-network provider, a dental indemnity plan lets you pick your preferred doctor. The insurer will set a “usual and customary” amount that they’ll cover for different procedures. If the amount your insurer pays doesn’t match the amount on your doctor’s bill, you’ll have to pay the difference.

Those are some of the major dental policy types. Keep in mind that these insurance plans don’t always include orthodontic benefits in a basic plan. You might need to buy one of the “upper tier” plans to get that level of coverage.

Dental discount plans

A dental discount plan is not insurance, but it will help you save money on your dental costs. Instead of monthly premiums, you’ll pay a small membership fee (often an annual one). In return, you get access to member-only discounts on a wide variety of dental services. You still foot the bill for the entirety of your treatment. But thanks to your discount program, you’ll pay a bit less.

For example, some discount plans might give you 60% off on routine preventative care, 40% off services like fillings, and 10% off all other services. Granted, each plan varies, but that’s roughly how it works. In some cases, you can get a dental discount plan directly from a dentist. But other times, you can join a discount network.

HSA

Short for health savings account, an HSA is a savings account that you can contribute to year over year. The real benefit to an HSA is that you can stash the money before it is taxed without penalty. The catch? Once you add that money to your HSA, you can only use it towards qualifying health expenses.

In many cases, “qualifying health expenses” can include dental treatment. Sometimes it includes orthodontic treatment, too, but you’ll have to check the terms of your plan. Not everyone qualifies for HSA; they’re reserved for individuals and families that are covered under high-deductible health plans.

Another advantage to an HSA is that your money earns interest, and the money stays in your account year over year. That said, you can only contribute so much (and avoid taxes) annually. Individuals can contribute as much as $3,600 per year, and families can max out their annual contribution at $7,200.

FSA

An FSA, or a flexible spending account works a lot like an HSA: you stash away money with a tax advantage. These accounts are usually offered by employers, and reimbursement is filed through the employer, too.

Like an HSA, you can only use the money for qualifying health and dental expenses. There’s also a cap to how much you can contribute: $2,750 for individuals and another $2,750 if you’re married. But unlike an HSA, the funds you stash away don’t carry over year to year…mostly. If you reach the end of the year, one of two things will happen (depending on the terms your employer sets up). On one hand, you might have 2.5 months to spend what you can. Alternatively, your employer might let you carry over $550 into next year. But you’ll have to check with your employer to know for sure.

How To Get Dental Insurance

Dental insurance is a little complicated, but thankfully, it isn’t too hard to get. There are a few different ways to get it, too.

The easiest, simplest way is to get employer-sponsored dental insurance. Frequently, at least one of the plans offered by your employer will include dental benefits. There’s no guarantee, of course. But for many adults, this is the easiest way to get coverage.

But let’s say you’re unsatisfied with the coverage you get with your employer’s plan. Or you’re self-employed. Thankfully, you can get additional coverage (or your first policy) on your own. There are a lot of good online resources to find dental insurance policies; eHealth, HealthCare.gov, and HealthCare.com are just a few examples. These resources will ask you a few questions about the coverage you want, your income, how long you want coverage, and so on to help match you with potential plans. From there, you can move on to each insurer’s website to learn more.

If you go the self-shopping route, be sure to read the terms and conditions carefully. This is especially important if you’re hoping for orthodontic benefits; those are included in some plans, but it’s not a given. Also make sure you’re sure of your copay, your coinsurance, your deductible, your annual benefit limits, and all those important details before you sign up.

Unlike health insurance, dental insurance does not have an enrollment period; you can sign up at any time. So you can add on additional coverage when it’s most convenient.

Want orthodontic benefits more than anything? You’re not alone. We can’t offer a comprehensive list of companies that offer them, but here are a few worth looking into:

• Aetna

• Guardian

• Anthem

• Blue Cross Blue Shield

• UnitedHealthCare

Curious how much signing up for your own plan will cost you? You’re not alone. Cost is always a factor, after all. We can’t guarantee what your plan will look like. But on average, most people spend an average of $300-$700 annually for insurance. Monthly payments usually range between $15 and $50 depending on your policy.

What Type of Insurance is Best for Me?

There’s no one-size-fits-all answer to this question. But in general, with a little math, you can get a feel for what type of insurance is right for you—if it’s right at all. What would you pay out of pocket with insurance? How about without?

Let’s say, for example, that you take really good care of your teeth. You have zero problems, and you go to the dentist twice per year as you should. In that case, you’ll pay (at a minimum) fees for a full round of X-rays, two cleanings, and a fluoride treatment at each exam. That last one’s an elective service, but it’s recommended to maintain your good dental health. Costs for these procedures vary, but here are some averages:

• Cleaning: $90-$120

• X-rays: $120

• Fluoride: $20-$50

Location does play a factor, too; some areas simply have higher costs for dental care. In the most expensive areas, average annual dental costs can add up to $360-$400. That’s not too bad, really. So if you’re only getting routine preventative care, then dental insurance probably isn’t worth the added expense. The typical deductible falls close to $400 (sometimes higher), so you’d just break even on out-of-pocket costs. And that’s not including your monthly premium, either. If this is you, a dental discount program might be a better approach.

But let’s say you get the occasional filling, or you have multiple people on your policy. Then things change. The procedures get pricier. One tooth-colored filling, for example, costs between $150-$300 without insurance (the bigger the filling, the bigger the price tag). As costs like this add up, insurance looks better and better.

Even pricier procedures like root canals and crowns (which easily add up to $1,500 or more without insurance) make insurance look incredibly appealing. The same applies for pricier cosmetic procedures like implants or orthodontic treatment.

Once you’ve decided that dental insurance is right for you, you’ll want to evaluate which type is best for you. This decision can be largely based on personal preference. For example, if you already have a dentist that you like, you should ensure your doctor is in-network with the insurance company you choose. Alternatively, you could sign up for a plan that lets you choose your own doctor.

How Do I Know if My Treatment Will Be Covered?

First, you have to meet your deductible each year. There’s no avoiding that. But after that, once your benefits kick in, it’s still not guaranteed that all of your care will be 100% covered.

Again, each insurance policy varies. But in general, routine preventative care is covered (post-deductible, of course). This includes general cleanings, fillings, x-rays, and sometimes even sealants and fluoride. Many of the more extensive treatments will cost you more out of pocket: veneers, root canals, implants, and so on. Keep in mind that these add up quickly, and it’s not hard to exceed your maximum annual benefit. If that happens, you’ll have to pay the rest out of pocket (so pace yourself if you can).

A lot of questions come up when you start talking about orthodontic benefits. Unfortunately, orthodontic procedures aren’t always covered. And some insurers will cover certain types of treatments and not others. For example, many providers are more likely to cover traditional orthodontic treatments like braces or Invisalign. But they might not cover at-home clear aligners like Byte or Candid. Others will.

Teledentistry—the industry term for remote dental care, like home clear aligners—is perfectly safe. But since it’s relatively new, not all insurance companies will cover it. That said, this stance is changing rapidly. Aetna, UnitedHealthCare, and Guardian are just a few of the companies that will cover part of remote clear aligners.

One last note: many insurance companies have a “waiting period” before they’ll cover large expenses. For example, they might not cover more than a couple hundred dollars for the first six months that you’re a customer. As a general rule, it’s best to sign up for insurance before you need any hefty work done.

Other Ways to Cut Costs

Orthodontic treatment is pricey, and if your insurance company won’t contribute towards the cost, you might feel a bit lost. Thankfully, there are a few non-insurance ways to cut costs. For starters, if you have an FSA or HSA, you can put those funds towards your treatment. You can also consider using programs like CareCredit or SplitIt (provided your dentist or orthodontist accepts those methods).

Alternatively, tell your doctor up front that you’ll be paying for your treatment out of pocket. Many offer discount plans, and some will even give you a discount for cash payments. And almost all orthodontists will help you work out a payment plan so you can pay in installments and offset the cost.

Want to cut costs even further? If you have a mild to moderate case of misalignment, consider an at-home clear aligner treatment like Byte or Candid. Since these companies treat patients remotely (but still safely!), they have minimal overhead costs. And lower operating costs means lower prices for you. Take Byte, our favorite company. They charge just $1,895 for daytime treatment. Often, that price tag (without any insurance benefits) is still cheaper than what you’d pay for Invisalign or braces…even with insurance coverage.

Best Teeth-Straightening Options If You Don’t Have Insurance

We’re rather impartial to clear aligners (it’s in our name, after all). But our preference aside, at-home clear aligners are a fantastic option for uninsured grinners. You can get Invisalign results without the Invisalign price tag. What’s not to love about that? Here are a few of our top picks for remote treatment.

Conclusion

Phew! Insurance is tough to talk about, isn’t it?

Hopefully this detailed guide has helped clear up any questions you have about dental insurance. If you’re searching for a new policy, we wish you the best. And if you’re ready to pursue orthodontic treatment, let us be the first to congratulate you on your new smile!